Week 1: April

April picture

A young woman, April, is sitting in the waiting area. Paul opens the door and invites her in.

Paul’s office has large bay windows and is comfortably furnished. April walks around looking and admires the office, mentioning she is an architecture student. She asks if he did it himself or used a decorator and when he says he did it, she congratulates him.

April tells him she is 23, a student in architecture and urban planning at Pratt. She is recently single, having just broken up with a long time boyfriend. Paul asks if that is why she has come and she says no, the breakup was fine. She says she found his name online because she wanted to see someone near Pratt who would take her insurance. She tells him no one had commented and she had assumed it was a new practice. He tells her he recently moved there. Paul tells her she needn’t apologize for questions and that she needn’t censor herself to spare his feelings. He asks if she has seen a therapist before and she says she had —  through student health. She speaks scornfully of the previous therapist. She felt that that therapist saw her as a complete waste of time. She  tells Paul that the therapist had told her the same joke twice. Paul asks about it and she tells him. April stopped going and never spoke to the therapist despite receiving many telephone calls from her. She says she did not return the calls or tell her because she didn’t ant to hurt her feelings. April gets angry and defensive at Paul’s questions about her previous therapist.

Paul reflects to her that he knows now that she doesn’t want him to tell her things twice, not to feed her platitudes, that if he fails to engage her she will leave him without telling him even if he calls her 87 times.

She likes that and asks how many people come to her because of something really big. He tells her she can tell him anything — a rape or death. She tells him she was not raped and she is trying to tell him. Then she asks if she can write it down and he says of course. She writes and she is clearly upset. She hands him the paper. She looks terribly ad and so does Paul. He asks how she feels  — she replies she is tired. He asks what type of cancer it is. She says she doesn’t want to talk about it. She just wanted to tell someone and she rushes into telling him all the things she has to do. He asks if she is getting sleep and she says no, she has terrible night sweats which are a symptom of lymphoma. He asks how she found out. She tells him she had a cough that wouldn’t go away. She went to the health center but what they gave her did not help. Her father is a doctor in the Army and she couldn’t reach him. Her symptoms got worse so she returned to the health center. Finally she was sent for further tests and she was diagnosed. She has a big mass behind her spine. She tells him to never get a bone marrow biopsy and describes how bad the experience was. She has met with an oncologist. He asks if she was alone when she did and she says she was. He asks if she has told her parents or friends. And she says she has only told him and a construction worker who harassed her on the street. She says she wanted to talk someone who is objective and won’t care what she does so she can talk about what she wants. She says her mother would become hysterical as would her father. Her brother, who is autistic, she says would become violent. Paul asks if she came to him looking for someone who would tell her it’s okay not to get treatment and she says no. Paul asks her if she really believes she has cancer, does she believe what she knows?

April tells him the oncologist said she was at stage 3 and she should start chemotherapy immediately. Paul challenges her resistance to starting treatment. Paul suggests to April that the other therapist told her the same story twice as a way to tell her it’s okay to need help. Paul says she needs to tell the oncologist what she is contemplating and that she needs to tell her parents as well. April gets angry and wants to leave. Paul offers her another time and presses to schedule another. She says she will call him. Paul is worried. She leaves.

April presents Paul with some interesting issues. He knows she will leave if he does not meet her expectations for his behavior, if she feels he has not listened and really heard her. And she is also in denial about the seriousness of her illness and the necessity to allow people to help her and to engage her in treatment. So he must find the line between listening and confrontation that will allow her to stay. The threat of abrupt termination is hanging over the therapy from the outset and Paul knows this.

Notice how Paul understood from what April told him about the first therapist and her scorn for her that she was telling him what would lead her to similarly reject him. And in fact she is primed to reject him because she is deeply ambivalent about getting help of any kind. It is not uncommon for patients to tell us how we will fail them, and we often do exactly that because it is an unconscious agenda for the therapy. The trick is in getting the patient to be willing to work through what they feel as a failure of empathy in order to see the greater complexity of the issue.

Paul is hoping April will come back. He stepped on the mine when he bluntly told her she needed to allow herself to be helped and to tell her parents. But he also earned some credibility in her eyes when he got what she was saying about the previous therapist. The odds favor her return. But it was a gamble he had to take on the chance that she did not return, a chance which was present from the very first moment of their meeting.